Robotic VRAM Flap for Pelvic Reconstruction: Technical Tips and Pitfalls

Study Objective

To demonstrate the surgical steps, key technical pearls and discussion of pitfalls of robotic-assisted vertical rectus abdominis myocutaneous (VRAM) flap reconstruction.

Design

This is a surgical video presentation detailing a single case with stepwise narration, supported by intraoperative footage.

Setting

in a tertiary academic center using the da Vinci robotic platform. In dorsal lithotomy, robotic trocars placed contralateral to the flap harvest site, including a transumbilical camera port, bilateral lower trocars and and two additional trocars to contralateral side of flap.

Patients or Participants

A 46-year-old woman with a history of anal cancer treated with radiation presented with vaginal stenosis and hematocolpos. The patient underwent reconstructive surgery.

Interventions

After total hysterectomy and rectovaginal dissection, a right-sided robotic VRAM flap was harvested. Key steps included skin paddle incision, mobilization of the rectus muscle, division below the costal arch, preservation of the inferior epigastric artery above and below arcuate line, creation of the neovagina with tubularized flap anastomosed in a V-pattern, and completing by closure of rectus sheath. Intraoperative pitfalls include injury to the vascular pedicle and excessive flap bulk affecting urinary or rectal function. We discussed strategies to reduce tension and flap volume, such as narrowing the paddle, avoiding full skin paddles, and rotating on the diagonal axis.

Measurements and Primary Results

Intraoperative perfusion was confirmed by visual inspection of the flap. The reconstructed neovagina measured approximately 10 cm in length and 4 cm in width. There were no intraoperative complications.

Conclusion

Robotic VRAM flap reconstruction offers a well-vascularized flap for pelvic and vaginal reconstruction particularly in patients with prior pelvic radiation. Compared to open surgery, robotic approach preserves the anterior rectus sheath, improves flap viability, and reduces donor site and perineal wound complications. This technique represents an effective, reproducible strategy in complex pelvic reconstruction.